Provider Demographics
NPI:1316940950
Name:BOLTZ, ROGER (OD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:BOLTZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 CALHOUN RD RM 2107
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77204-2020
Mailing Address - Country:US
Mailing Address - Phone:713-743-2020
Mailing Address - Fax:713-743-0963
Practice Address - Street 1:4901 CALHOUN RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77204-2020
Practice Address - Country:US
Practice Address - Phone:713-743-2020
Practice Address - Fax:713-743-0963
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2128T152W00000X
TX2128TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112409104Medicaid
TX00E63GMedicare UPIN
TX112409104Medicaid
TX037079301Medicaid
TX112409104Medicaid